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Focused Neuro Exam
Loren Bellows
Norwalk Hospital – Surgery Rotation
Comprehensive Neuro Exam
Components
• General Appearance
– Posture, motor activity, speech
• Mental Status exam
• Cranial Nerves
• Motor Function
– Atrophy, tone, strength
• Sensory
– Vibratory, Position, sharp/dull, temperature
• Reflexes
• Cerebellar
– Coordination, gait, Romberg’s
Focused Neuro Exam
• Three Exam Classifications
– The Comatose Patient
• Unresponsive, Profound state of unconsciousness
• Example: Trauma, Neurogenic Shock
– The Patient with Central Neurologic Disorder
• Dysarthria, Aphasia, Partial Paralysis
• Example: Stroke, Intracranial Bleed
– The Patient with Spinal Cord Disorder
• Dysaesthesia, Incontinence, Pain, Weakness
• Example: Disk Herniation, Spinal Cord Compression, BrownSequard Syndrome
Focused Exam: The Comatose Patient
• Glasgow Coma Scale
6
5
4
3
2
1
Eyes
N/A
N/A
Opens eyes
spontaneously
Opens eyes in
response to
voice
Opens eyes to
painful stimuli
Does not
open eyes
Verbal
N/A
Oriented,
converse
s
normally
Confused,
disoriented
Utters
inappropriate
words
Incomprehensible
sounds
Makes no
sounds
Motor
Obeys
commands
Localizes
painful
stimuli
Withdraws
from painful
stimuli
Decorticate
posturing
upon painful
stimuli
Decerebrate
posturing upon
painful stimuli
Makes no
movements
Interpretation: GCS < 8 = Severe,
GCS 9-12 = Moderate,
GCS > 13 = Minor
Focused Exam: The Comatose Patient
(con’t)
• Brain Reflexes
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Oculocephalic Reflex (Doll’s eyes)
Babinski
Gag Reflex (CN 9, 10)
Corneal Reflex (CN 5)
Cold Calorics
Pupillary Response
Response to Pain
DTRs
Gaze (Ping-Pong Gaze)
Focused Exam: Central Neuro
Disorder
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CNs
Speech
Coordination
Pronator Drift
Motor
Sensation
Proprioception
Graphesthesia
Stereognosis
Focused Exam: Spinal Cord Disorder
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Sensation
Motor
Hot/Cold
Vibratory Sense
Proprioception
Gait
DTRs
Rectal Tone
Hoffman’s Sign
Motor Function Testing
• Lack of Consistency:
– Patient: 90 y/o female vs. 20 y/o male
– Examiner
• Motor Weakness helps to pinpoint spinal cord
lesion
Keys to the Motor Exam
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Have patient perform movement First!
One side at a time; Compare R vs L
Examiner: Use the same hand throughout exam
Examiner: Don’t be a wimp! Use full and consistent
strength (unless there is known injury).
– Use single muscle group, i.e. don’t use your body weight to
oppose.
• Important to assign a specific response to a set grade
• Test Certain Muscle Groups
Grading Strength
• 5/5: Examiner is unable to overcome patient
• 4/5: Examiner is able to overcome patient; patient
demonstrates moderate resistance
• 3/5: Patient able to overcome gravity only
• 2/5: Patient unable to overcome gravity, but can
move joint
• 1/5: Muscle “fires”, but no joint movement
• 0/5: No muscle response
• May use +/- to differentiate further
Strength Testing: The Muscle Groups
• Upper extremities:
Action
Nerve Root / Spinal Level
Shoulder Abduction
C5
Elbow Flexion
C5/C6
Elbow Extension
C6/C7/C8
Wrist Extension
C6
Wrist Flexion
C7
Grip Strength (Finger Flexion)
C8
Interosseous (Finger
Ab/Adduction)
T1
Strength Testing: The Muscle Groups
• Lower Extremities:
Action
Hip Flexion
Nerve Root / Spinal
Level
L1
Knee Extension
L3
Ankle Dorsiflexion
L4
Great Toe Extension
L5
Ankle Plantarflexion
S1
Nerve Root Landmarks
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C3 – Front of Neck
T 4 – Nipples
T 10 – Umbilicus
L3 – Knee
L4 – Medial LE
L5 – Lateral LE &
Great Toe
Questions??